New Patient Application 
Hello, we're glad you're here! In order to ensure the best and safest care possible, we carefully review all new patient requests to make sure your unique needs are within our scope. Please fill out some general information below and our team will review it as quickly as possible.
If we are able to meet your needs, a team member will be in touch to begin the registration process so you can be scheduled for that first appointment. 
If we are unable to take you on as a patient, or are out of network with your insurance, a team member will let you know about that as well. 
Sign in to Google to save your progress. Learn more
Email *
Legal first and last name of the patient *
Preferred name (if different from legal name)
Patient Date of Birth *
MM
/
DD
/
YYYY
Phone number *
Insurance provider *
Were you referred by a therapist or other provider? *
If yes, who referred you?
What is the reason you are requesting consultation and what symptoms are you experiencing?
 *
Have you taken any psychiatric medications in the past?
 *
If yes, please list the medications here. 
Have you been diagnosed with any of the following? (Please check all that apply)
 *
Required
Please list any other medical diagnoses.
 *
Any psychiatric hospitalizations?
 *
Any history of thoughts of self-harm or attempting to hurt yourself?
 *
I understand that by filling out this form, I am authorizing Clark and Schulze NP Practice to review shared medical records with area healthcare facilities to verify any information provided regarding medications or past medical history.  *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of clarkandschulzenp.com. Report Abuse
Google Forms